15 November 2010

Catastrophe looms if doctors act on fears

Many Australian doctors have contemplated quitting medicine, cutting back work hours or retiring early because of medicolegal fears, according to the largest Australian study of its kind.

Experts agree that if they acted on those fears it would be a catastrophe for the health system.

The study, reported in this week’s MJA, confirmed the findings of similar international studies, including that medicolegal fears led to increased referrals and ordering of more tests as well as improving communication and quality and safety measures.(1)

Doctors in the Australian study who had been the subject of a medicolegal matter were more likely to change the way they practise or consider leaving medicine than those who had not.

The study involved a cross-sectional survey conducted in September 2007 of specialists, registrars, specialists–in-training and a sample of GPs insured with one medical insurance company.

Experience of medicolegal matters was self-reported by 1902 of 2942 respondents (65%), with 426 (14%) having a current matter.

The two most common medicolegal matters were claims for compensation (31%) and complaints to a health care complaints body (30%).

Concerns about medicolegal issues led 33% to consider giving up medicine, 32% to consider reducing their working hours, 40% to consider retiring early and 18% to feel more emotionally distant from patients.

Also, 43% said they referred more patients, 55% reported ordering more tests and 11% said they prescribed more medications than usual.

The survey respondents also reported improved communication of risk (66%), increased disclosure of uncertainty about diagnosis or treatment (44%), development of better systems for tracking test results (48%), and better methods for identifying non-attenders (39%) and auditing clinical practice (35%).

The study authors called for education of doctors to include knowledge of the medicolegal environment and an understanding of how medicolegal concerns may weaken clinical judgement, cause unnecessary costs, burden health care resources, and constrain improvements in health care delivery.

Professor Simon Willcock, one of the study authors and a member of the Avant Mutual board of directors, said he knew of at least two doctors who had left practice in the past decade.

“These were both doctors in their middle years in the middle of a busy practice who, after a particularly traumatic medicolegal event, left practice,” he said.

However, Professor Willcock said some of the changes in practice reported in the study, such as better report-tracking systems, were positive.

“But if everybody reduces by 10% the number of hours they are working, you are going to need 10% more doctors just to fill the time,” he said.

Professor Willcock said the best way for doctors to allay their fears was by education, risk minimisation, learning effective communication skills and having appropriate recall and follow-up systems in place.

Elizabeth van Ekert, professional services adviser with MDA National and a co-author of the study, said although the survey showed some doctors were considering leaving practice, there was no evidence they actually did.

“Obviously, if they did leave in droves, it would be a catastrophe but we just can’t see that that is going to happen,” she said. “They contemplate it but don’t necessarily act on it.”

Cheryl McDonald, claims department manager with MIGA, said some doctors involved in claims for compensation could feel quite damaged.

For some who were considering retiring or reducing their hours, a claim could be the last straw, she said.

“Just because someone might complain about you one day or you might be the subject of a claim, surely that should not be the driver for making a career decision in what is otherwise a very productive and highly regarded career,” Ms McDonald said.

The fear of litigation was not a big component in my decision to quit now, as I have been very careful since a false allegation was made against me 20 years ago. Although I did quit then for 6 months, and only resumed practice in a group situation that offered more protection. But it was a factor.
More important was the extra unpaid paper work generated by the bureaucracy, and the nuisance value of lawyers trying to stretch the boundaries of patients’ right of access to health records. Fixed costs which made it not worth working less than 30 hours a week were a factor too, as were the CPD requirements. If anything I found meeting the requirements actually detracted from my professional development by making me concentrate on repetion of the old and mundane for the points instead of putting the time into new learning. Again that demanded extra time spent for little extra result.